Provider Demographics
NPI:1356404701
Name:NOVACK, STACEY L (PSYD)
Entity type:Individual
Prefix:DR
First Name:STACEY
Middle Name:L
Last Name:NOVACK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 MAIN ST
Mailing Address - Street 2:SUITE 212
Mailing Address - City:NORTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01060-3109
Mailing Address - Country:US
Mailing Address - Phone:413-586-0222
Mailing Address - Fax:
Practice Address - Street 1:25 MAIN ST
Practice Address - Street 2:SUITE 212
Practice Address - City:NORTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01060-3109
Practice Address - Country:US
Practice Address - Phone:413-587-7760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
MA8780103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist